Medical Release for New Phase Development

6914 Office Park Circle, Knoxville, TN 37909

(T) 865-200-8364 (F) 865-588-1055

AUTHORIZATION FOR DISCLOSURE OF MEDICAL INFORMATION

1. I hereby authorize the use or disclosure of my health Information as described below. I understand the Information disclosed under this authorization may be subject to redisclosure by the recipient and no longer protected by federal privacy regulations.
Patient Name*
Date of Birth*

MonthDayYear
Date
Address
Street, City, State, Zipcode
Telephone
Covering the period(s) of health care: From (Date)*
Year
To (date)*

MonthDayYear
Date
2. Information to be disclosed

Complete health record(s)
OR ONLY (check as many as appropriate)

History & Physical ExaminationsProgress (VIsit) NotesConsultation ReportsBilling/FinancialLaboratory TestsX-Ray ReportsPhotos, Tapes, X-Rays or Any Images
3. (Initials) I specifically consent to the release of any information related to testing and treatment for HIV, AIDS, mental health/psychiatric care, or alcohol and/or drug abuse if such is contained in the medical records. THIS PROVISION MUST BE INITIALED BY PERSON GIVING CONSENT OR THIS INFORMATION WILL NOT BE RELEASED.*

Clear
4. I authorize this information to be disclosed to New Phase Clinical Research & Development.*

Yes
5. I authorize this information to be disclosed by the following practice/hospital/etc.:*

Yes
Practice/Hospital/Etc. Name*
Doctor/Practitioner*
Provider Address
Provider Telephone
Provider Fax
6. I authorize New Phase Research & Development to disclose my information to the physician listed above.*

Yes
7. I understand this authorization may be revoked In writing at any time, except to the extent that actlon has been taken In reliance on this authorization. Unless otherwise revoked, this authorization will expire forty-five (45) days from the date signed below.

8. I understand that I have the right to refuse to sign this form. Refusal to sign, this, authorization may result In the in physician declining to provide research-related treatment.
Patient Signature

Clear
Date

MonthDayYear
Date
Should be Empty: